Iowa has one of the highest percentages in the U.S. of foster children on psychotropic medication and does a poor job of monitoring the use or effectiveness of those drugs, a study released this month shows.

The U.S. Department of Health and Human Services Office of the Inspector General found Iowa, Maine, New Hampshire, North Dakota and Virginia led the nation with the greatest percentages of foster children on psychotropic medications.

In Iowa, 36 percent of 13,951 children in foster care were treated with psychotropic medications at a cost of $7.1 million, the inspector general found. That’s significantly more than the roughly 30 percent nationally.

Iowa requires that all children in foster care have a treatment plan — in part to prevent harmful side effects — but the study found 30 percent of those being treated with the drugs did not have one.

Matt Highland, a spokesperson for Iowa's Department of Human Services, said while the report outlined "some practice concerns, we believe the issue is one of documentation. … We are in the process of identifying what, if any, additional steps should be taken to ensure proper oversight."

Medical professionals and advocates have raised alarms about over-medicating foster children. As many as four in five have significant mental health needs.

But the medications used to treat them can have serious and harmful side effects, including drowsiness, weight gain, nausea, headaches, involuntary movements and tremors.

The inspector general’s study concluded the Administration for Children Families should "develop a comprehensive strategy to improve states’ compliance with requirements related to treatment planning and medication monitoring for psychotropic medications."

An advocate for child welfare reform nationally said states such as Iowa need to stop putting so many children in foster care or find more family members to care for children when they can’t go home.

"It’s really just one more indication … that Iowa and other states have been doing (foster care) wrong,” said Richard Wexler, executive director of National Coalition for Child Protection Reform. “You can’t fix this with another layer of bureaucracy and another form to fill out. You fix it by putting children with those who love them.”

Wexler said foster parents are more likely than birth families to rely on medication to keep children “docile and compliant,” or turn to group homes and institutions “which is where is the problem tends to be greatest.”

But Dr. Stephen Mandler, chief medical officer and psychiatrist at Orchard Place, said the problem in Iowa is more complex.

“It’s not simply that foster parents and doctors want to over-medicate,” he said.

Iowa, he said, has fewer child psychiatrists per children than most states, he said.

The result is that physicians, pediatricians and nurse practitioners are prescribing medication without the necessary expertise, guidance or follow-up. The result for children can be higher doses or “med stacking” that can be harmful.

Foster children often are exposed in utero to drugs and severely traumatized in ways that can harm brain development, he said.

“They are some of the most difficult and challenging to treat because of the severity of their trauma and their condition,” he said.

Mandler said Iowa could address the shortage of pediatric psychiatrists with a program that would allow them to pay back student loans at a lower rate. Insurance reimbursement rates based on quality care with a child and family, instead of those that reward providers for seeing a high number of children in a short period, would also help.

A pediatric collaborative model that compensates psychiatrists who offer consulting to pediatricians also would allow for safer care, he said.

Highland said Human Services also began using an assessment in May 2017 that requires a screening for all medications and dosages taken by foster children that is reviewed every 90 days.

"These practices are not reflected in the data used in the report, as they were being implemented around the same time period," he said.

Human Services also is taking steps to develop more front-end services for families and modernize its child-welfare information system, which will greatly improve and expedite social worker documentation, he said.

Lee Rood's Reader's Watchdog column helps Iowans get answers and accountability from public officials, the justice system, businesses and nonprofits. Contact her at lrood@dmreg.com, 515-284-8549 on Twitter @leerood or at Facebook.com/readerswatchdog.

What the study found

Iowa requires caseworkers to visit children in foster care monthly — in part to determine whether they are receiving appropriate medical care. Caseworkers must document medications, why they were prescribed and whether they meet the child's needs.

But the inspector general found 30 percent of the almost 14,000 children in foster care had no treatment plan. In addition:

48 percent of foster children did not receive medication monitoring by a prescribing professional.

83 percent of foster children had no evidence a caseworker inquired with the foster family as to the effectiveness of medications prescribed.

72 percent of children showed no evidence the medication was meeting their needs.